Glossary (O)

Managed care plan that allows members to see participating providers, usually specialists, without a referral from a primary care doctor.

open enrollment

A period during which subscribers in a health plan can change their health coverage.

A period when uninsured individuals can obtain coverage without presenting health statements.

oral and maxillofacial surgeon

A licensed dentist who has advanced training and demonstrated competency through examination or other evaluative processes to perform surgery on the lower jaw and dental structure. See also dentist.

orthotic appliance

A device, such as a leg brace, worn outside the body to correct a body defect of form or function. See also prosthetic appliance.

other-than-group coverage

Coverage provided for individuals who are not associated with any kind of group.

outcome measures

System used to track clinical treatment and responses to that treatment.

outcomes management

Collection and analysis of medical performances based on certain specifications.

outliers

Services or costs that differ substantially from the standard established in a statistical profile of cost or usage.

out-of-area benefits

Coverage available to individuals living or traveling outside a health plan’s service area.

out-of-network copayment

The dollar amount or percentage of the Blues-approved amount that the member must pay under a PPO, POS or other managed care plan when going to a non-network provider without an appropriate referral. Same as sanction.

out-of-network services

Services performed by a provider who has not signed a contract with the member’s health plan to be part of a provider network.

out-of-pocket maximum

The highest dollar amount a member or family must pay in combined copayments and deductibles during any given year.

outpatient surgery

See ambulatory surgery.

outside referral

Service provided by a consultant provider, usually a specialist who is outside the plan’s network.